MEDICAL NECESSITY CLINICAL REVIEW SPECIALIST FT
About The Position
The Medical Necessity Clinical Review Specialist supports Legent Health’s revenue integrity process by conducting pre-service case reviews to ensure that surgical and procedural cases meet payer-specific criteria for medical necessity prior to service. Utilizing Legent’s AI-Enabled Medical Necessity & Authorization Tool, this role assists with identifying documentation gaps against payer guidelines, preparing gap analyses for physician review and education, and establishing clinical criteria to support appeals when needed. The specialist collaborates with authorization teams, facility leadership, physicians, and revenue cycle staff to strengthen the organization’s pre-service review processes.
Requirements
- Medical Assistant, Licensed Vocational Nurse (LVN), or Registered Nurse (RN)
- Minimum 2 years of clinical or healthcare experience in a surgical, procedural, or hospital setting
- Clinical knowledge of orthopedic, spine, pain management, endoscopy, and general surgical procedures
- Understanding of payer medical necessity criteria, prior authorization processes, and clinical documentation requirements
- Proficiency with computer systems, EMR navigation, and payer portals
- Strong attention to detail and ability to interpret clinical documentation against payer guidelines
Nice To Haves
- Experience in a revenue cycle, utilization review, or prior authorization role
- Familiarity with surgical hospital and ambulatory surgery center operations
- Experience working with AI-powered clinical or revenue cycle tools
Responsibilities
- Conduct pre-service case reviews to ensure cases meet payer-specific medical necessity criteria as part of Legent Health’s revenue integrity process
- Utilize the AI-Enabled Medical Necessity & Authorization Tool to assist with pre-service medical necessity reviews and authorization documentation review to identify gaps with payer guidelines
- Review cases that do not meet clinical criteria or as deemed necessary by department leadership
- Prepare gap analyses for physician review and education to support complete and accurate clinical documentation
- Establish and document clinical criteria to support appeals when needed to ensure appropriate claim payment
- Provide guidance and support to facility leadership teams as necessary regarding medical necessity and authorization requirements
- Collaborate with the authorization team to ensure seamless coordination between clinical review and authorization workflows
- Provide support to the revenue cycle team as needed to help improve pre-service processes and outcomes
Benefits
- Competitive salary and performance incentives
- Comprehensive benefits package
- Paid time off and wellness programs
- Career development and training opportunities
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
